Posterior Shoulder Tightness
Overhead athletes have been know to have increased external rotation and decreased internal rotation of the dominant shoulder when compared to the contralateral side. This is referred to as GIRD (gleno-humeral internal rotation deficit). Patients are usually asymptomatic with a deficiency of less than 20o or less than 10% of the total motion seen in the non-throwing shoulder. There may come a point where this decrease in internal rotation can become symptomatic resulting in pain in the shoulder with activity.
As always the evaluation of any patient begins with a full history. These patients usually complain of pain during late cocking or early acceleration phase of throwing. The physical exam starts with inspection of the skin and surface anatomy for any gross abnormality. Next, a thorough neuro-vascular evaluation of the upper extremity is performed. Following this range of motion both actively and passively, strength testing, neck exam and any other specific physical examination tests determined necessary are performed.
ROM may be performed either seated or supine, and external rotation and internal rotation may be performed either by the side or with the arm abducted 90o.
GIRD has been postulated as an early finding that can lead to a cascade of events if not addressed early. This posterior capsular contracture can lead to SLAP tears, anterior labral or capsular failure, and rotator cuff pathology.
Posterior capsular contracture has been shown to develop over time in these athletes. It appears that the longer this deficit has been present and the higher the level of competition these athletes participate in the less likely it will respond to non operative treatment. Non-operative treatment consists of a good posterior capsular stretching program as with a “sleeper stretch”. If this fails then patients may respond with a posterior capsular release with concomitant repair of other symptomatic pathology.
References
1. Burkhart SE, Morgan CD, Kibler WB. The Disabled Throwing Shoulder: Spectrum of Pathology Part 1: Pathoanatomy and Biomechanics. Arthroscopy 2003; 19: 404-420.
2. Yoneda M, Nakagawa S, Mizuno N, et al. Arthroscopic Capsular Release for Painful Trowing Shoulder With Posterior Capsular Tightness. Arthroscopy 2006; 7: 801.e1-801.e5.
3. Kibler WB, Chandler TJ, Livingston BP. Shoulder Range of Motion in Elite Tennis Players Effect of Age and Years of Play. Am J Sports Med 1996; 24: 279-285.
4. Ticker JB, Beim GM, Warner JP. Recognition and Treatment of Refractory Posterior Capsule Contracture of the Shoulder. Arthroscopy 2000; 16: 27-33.
5. Bennett WF. Addressing Glenohumeral Stiffness While Treating the Painful and Still Shoulder Arthroscopically. Arthroscopy 2000; 16:142-150
Submitted by:
Ricardo Rodriguez, MD
Baton Rouge, LA
